1. ‘A Yellow Bleeder’ Kaushik Guha Shirin Zaheri Fariza Wan Jamaludin Shebina Hakda

2. HISTORY - MR. Y:  30y male, unemployed, known alcoholic liver disease  PC -  abdominal swelling and tenderness. *AMTS 7/10*  HPC - Admitted 3.7.03 feeling unwell 3/7 with abdo pain & rigidity, SOB, loss of appetite, nausea. - 4.7.03 : spontaneous haematemesis at 2350, throughout night. - Fresh, bright red blood with estimated loss: 3L. - Darkening of stool and urine since then - No itchiness  SE- Weight stable, constipation, low mood & anxiety. - No hx of previous haematemesis / NSAIDs / dyspepsia.  PMH - Meningitis ‘91 - Cirrhosis due to ETOH few years ago.  DH - NKDA Spironolactone-KCl Insulin-Chlordiazepoxide Pabrinex-Multivitamin supplements

3. FH - No alcohol dependence problem and liver diseases in the family SH - ETOH hx: Started drinking 15 years ago Present consumption: 29 unit/day of mainly cider Last drink was the day before admission. Drinks by himself at home, rarely goes to the pub CAGE questionnaireAlcohol dependence : 7/7 1. Cut down - Withdrawal symptoms: resting tremor, nausea 2. Annoyed - Detox programme in Springfield March ‘03 but 3. Guilt xunable to complete due to medical admission. 4. Eye opener Started smoking at 14yrs. Now smokes 20-30 cigarettes /day. Lives with father, he is very supportive. Substance abuse - Nil Forensic history - Nil

4. EXAMINATION - MR. Y: Pulse: 90/min, BP: 135/75, Temp: 36.7, Sats: 99%. App : Polite, alert, not encephalopathic. No further haematemesis. Palmar erythema- Xanthomas L palm. Leuconychia - Bilateral yellow sclerae. Multiple spider naevi on chest- Fine resting tremor CVS: Pulse 90, regular, sinus rhythm. JVP not raised HS I + II + 0, loud S II RESP : Rate 28/min, decreased air entry bilateral lung bases. ABDO: Distended, rigid, tense, mildly tender. Shifting dullness liver enlarged 2 cm below R costal edge no splenomegaly. NEURO: Unremarkable DDX : Decompensated liver impairment secondary to ETOH intoxication.

5. INVESTIGATIONS - MR Y: 1) FBC  Hb 10.1 (13-17)   WBC 6 (4-11)  PLATELET 71 (150-450)   MCV 95 (80-97)  RBC 3.11 (4.5-6)   3) LFT  BILIRUBIN66 (<17)   ALBUMIN27 (35-48)   ALT18 (<52)   GGT148 (<50)   ALP85 (30-100) 2) BIOCHEMISTRY  NA123 (135-145)   K4.2 (3.5-4.7)  CL - 96 (98-109)   HCO320 (22-32)   UREA2.1 (2.5-8.0)   CREATININE43 (60-110) 

6. MANAGEMENT - MR. Y:  Urgent endoscopy (OGD) 4.7.03 findings:  - fresh blood in oesphagus  - at least 6 varices with high risk stigmata, 1 varix spurting.  - fresh blood with clots in stomach, unable to exclude gastric varices as fundus not visualised adequately.  Lower stomach and 1st & 2nd part of duodenum normal.  5 bands applied - bleeding stopped but blood reflux from stomach.  F/U OGD 9.7.03 : 6 oesophageal varices  no red signs / no further bleeding / no banding ulceration  F/U OGD 29.7.03: 4 oesophageal varices  no red signs/ bleeding / ulceration  F/U OGD due in 4 weeks.

7. EPIDEMIOLOGY:  HAEMATEMESIS: vomiting of blood from a lesion proximal to the distal duodenum.  Accounts for 2500 hospital admissions each year in UK.  Annual incidence varies, 47-116/100,000.  Higher in low socio-economic areas.  Hospital mortality approximately 10%.

8. CAUSES OF UPPER GI BLEEDS:

9. OESOPHAGEAL VARICES-1:  Increases in portal pressure cause development of a portosystemic shunt  Anamostoses with the systemic circulation are commonly found in oesophagus, superior and inferior epigastric veins (caput medusae), superior and inferior rectal veins  Causes can be divided between prehepatic, hepatic and post hepatic  Commonest causes in West are alcoholic and viral cirrhosis, worldwide schistosomiasis hepatic infection

10. OESOPHAGEAL VARICES -2:

11. OESOPHAGEAL VARICES-3:

12. GASTRIC ULCER:

13. MALLORY-WEISS TEAR:

14.  Resuscitate - Airway - Breathing - Circulation  Assessment - History - Examination - Investigations MANAGEMENT OF UPPER GI BLEED:

15. INITIAL ASSESSMENT: Enquire about drug usage (esp. NSAIDS), EtOH, retching, previous dysphagia and dyspepsia Examine for signs of chronic liver disease Check for melaena by PR Take blood for Hb, U&E, LFTs, Grp & Save/Crossmatch and coagulation studies

16. INITIAL MANAGEMENT: Suspected GI bleed HIGH RISK LOW RISK Hb > 10g/dL <60 years and previously fit Coffee ground vomitus CVS stable Allow fluids Observe signs of continued or rebleed Endoscopy Next routine list Inform endoscopy by 9am High risk ‘stable’ Tachycardia > 100 Postural hypotension Co-morbidity Resuscitate Inform GI Bleed reg (air call) Endoscopy Within 12 hours Acute severe Hypotension Haematemesis/melaena Resuscitate Inform GI Bleed reg (air call) Surgical reg Endoscopy As soon as possible Surgeon in attendance GI bleed consultant informed

17. SECOND PHASE OF MANAGEMENT: VaricesBleeding continuesBleeding stopped Banding Sclerotherapy Balloon tamponade Urine output Inform GI team Prevent encephalopathy High risk Close monitoring Measure CVP Inform GI bleed team Low risk Discuss mgmt with GIB Reg Early discharge Plan for re-bleed Consultant endoscopySurgery Radiological intervention Options

18. RISK OF RE-BLEEDING: (Rockall Score)

19. Calculate Risk: Re-bleeding in 50% in 10 days. Prognosis worse in those admitted for other reasons and subsequently have an acute upper GI bleed, than those admitted solely for bleeding. Recurrence thought to be 60-80% 2 years after initial bleed.

20. LONG-TERM PREVENTION OF A RE-BLEED:  Banding: repeated at 2 weekly intervals, follow-up endoscopy.  any increase in survival?  Non selective beta-blockers (propanolol):  HR at rest,  portal pressure)   risk of re-bleed  intolerance  Isosorbide Mononitrate – releases nitric oxide  vasodilatation.  systemic vasodilatation  renal function

21.  Surgery – TIPSS (Trans-jugular Intra-hepatic Portal-System Shunt)  In portal hypertension of hepatic origin.  Failed endoscopy.  Bridge to subsequent liver transplantation.  When successful the shunt prevents recurrent variceal bleeding.  Encephalopathy occurs in up to 25%.  Intimal proliferation – shunt dysfunction.

22.  Liver transplantation is the treatment of choice in advanced liver disease.  Portal hypertension and liver function restored.  Survival at 1 yr is 80% and at 5 yrs is 60%.

23. REFERENCES: Bosch J et al. Prevention of Variceal Bleeding. Lancet 2003; 361:952- 54. Rockall TA et al. Risk Assessment after acute upper GI haemorrhage. Gut: 1996; 38:316-21. Kumar P, Clark M. (Eds) Clinical Medicine. 5 th Ed. 2002. WB Saunders. Logan R, Harris A, Misiewicz J, Baron J. (Eds) ABC of the Upper Gastrointestinal Tract. 2002. BMJ Books. Ball C, Phillips R. (Eds) Evidence Based On Call: Acute Medicine Pocketbook. 2002. Churchill Livingstone.